Treatment modalities addressing both biologic and esthetic demands are most often expected from today's periodontal practice. New technologies, instruments, and surgical techniques are necessary to help clinician ensure the best results and satisfy the patient's expectations. Microsurgical equipments help to enhance normal vision through magnification along with favorable lighting enabling to perform precise periodontal surgical procedures. With increasing awareness and the desire to get the best treatment among patients, these magnificent magnifying tools come handy for an innovative periodontal micro-surgeon. Here is an attempt to present the advantages of microsurgery offered in periodontics in this era of patient-driven dentistry.

There has been a tremendous advancement in the medical and dental fields to meet the patient's expectations and to achieve much desired therapeutic goals. Microsurgery is an advanced surgical technique in which the normal vision is enhanced through magnification. Modern periodontology is closely linked to both plastic surgery and esthetic dentistry. Periodontal plastic microsurgery incorporates the use of a surgical microscope in an attempt to increase visibility, thereby minimizing soft tissue trauma and enhance surgical results. The use of microsurgical instruments, improved view of root surfaces permit more definitive removal of calculus and better smoothness of root. The use of surgical operating microscope, microsurgical instruments has opened a new era in periodontal plastic surgery. Studies have demonstrated improved vascularization, enhanced mobility of flaps, and hence, possibility of obtaining primary wound closure, less post-operative discomfort, thus providing better esthetic results. [1] The success criteria of treatments performed to improve esthetics may be quite different compared to those surgical procedures whose main goals are to improve periodontal health and restore compromised function. [2] Further, the successful use of the surgical microscope in periodontal surgery is less documented with only few studies addressing the advantages of the application of magnification to periodontal surgery. [3],[4],[5],[6] Here, we present an overview of magnifying tools available and their applications in the specialty of periodontics.

Historical perspective

Westein, a mechanic from Rostock, constructed a binocular instrument from two Chevalier-Bruke loupes for the zoologist Shcultz. Zehender tried to adapt this instrument for ophthalmology, and the result was "Zehender-Westein" loupe. The father of microsurgery, Carl Nylen (1921), used surgical operating microscope for the treatment of otosclerotic deafness. Although Apotheker and Jako are credited to introduce surgical operating microscope to dentistry in 1978, periodontal microsurgery was first reported and popularized by Shanelac and Tibbetts in 1992. [7]

Types of magnification

The two types of optical magnification available to dentists are a) Magnification loupes b) Surgical operating microscope (SOM) [Figure 1].

Surgical loupes for magnification enable the clinician to experience the ergonomic benefits of an increased working distance from viewing object as well as improved visual acuity. The pattern of convergent lens system is called a Keplerian optical system.

Three types of Keplerian loupes commonly used in periodontics are:

i) Simple loupes, ii) Compound loupes, and iii) Prism loupes.

Simple loupes

Simple loupes are primitive magnifiers with limited capabilities, consisting of a pair of single, positive, side-by-side meniscus lenses. The disadvantage of simple loupe is that they are highly subjected to spherical and chromatic aberration, which distorts the image of the object that is being viewed. In spite of its cost advantages, the size and weight limitations make simple loupes impractical for magnification beyond 1.5 diameters.

Advantage

Low cost.

Disadvantage

Subjected to spherical and chromatic aberration, that ultimately distorts the image and color of the object that is being viewed

Their size and weight limits the practical application in dentistry, which is beyond a magnification range of 1.5 × diameters, hence distorting the image.

Compound loupes

The compound loupes are commonly mounted in or on the eyeglasses and can be adjusted to clinical needs without excessive increase in size or weight. Compound lenses can be achromatic (limits the effects of chromatic and spherical aberration and brings two wavelengths into focus in the same plane), which is an important feature for any magnifying loupe used in periodontics.

These loupes produce superior magnification since they contain Schmidt or roof-top prisms. Other technical advantages include: Better magnification, larger surgical view with wider depths of field, and longer working distances. Furthermore, because of the shorter barrels of the prism loupes, these loupes can be easily mounted on either eyeglass frames or head bands. The incorporation of coaxial fiber optic lights in prism telescopic loupes has improved the operative site illumination to a greater extent.

Loupe magnification range

The surgical loupes provide a wide range of magnification ×1.5 to ×10. In most of the periodontal procedures, prism telescopic loupes of 4x magnification, even though lower than the operating surgical microscope, provide an effective combination of magnification, field of view, and depth of focus.

The major disadvantage of loupes is that the clinician's eyes must converge to view on the operate field, which can result in eye strain, fatigue, and even vision changes when poorly designed loupes are used. But, loupes are less expensive and initially easier to use. [8]

Surgical operating microscope

"Pushing the boundaries of the possible in periodontics"

Surgical microscope utilizes the 'Galilean optical principles.' Optimal magnification factor for the periodontal surgery ranges from ×5 to ×12. The microscope mountings are available for ceiling, wall mount, or on the floor. Clinicians are not affected by the weight of the instrument or the challenges of maintaining a stabilized field of vision since they are external to the body. Surgical microscope has both maneuverability and stability. The fiber optic technology has improved the methods of focusing light on specific areas. Documentation of periodontal pathology and procedures of all types and video-documentation are also possible [Figure 2].

Loupes and operating microscope both improve the visual power and both increase the optical working distance causing increased and efficient work.

Problems that are common to a dentist such as eye, neck, shoulder, and back pains may be eliminated by using the surgical microscope.

Advantages of surgical microscope

Greater operator eye comfort because of the parallel viewing optics of the Galilean system as well as the range of variable magnification.

Excellent coaxial fiber optic illumination

Countless accessories such as still and video cameras for case documentaries [9]

Disadvantages

It is an expensive equipment.

Ergonomics

Various postural and ergonomic ways of reducing unwanted hand movements with the use of surgical microscope result in more precise surgeries and greatly reduce surgical fatigue and development of spinal and occupational pathology.

Clinical philosophy

Microsurgery is a surgical philosophy that improves the motor skills to enhance surgical ability. This enables decisive hand movements accomplished with increased precision and reduced tremors.

Consistent application of the philosophy and techniques which have been learned in basic microsurgery education is necessary for the operator so that he or she could attain a level of experience and competence needed for various periodontal surgical procedures. Training with the microscope enhances the motor skills, which can translate to improved surgical skills. The methods of precise, delicate tissue handling, wound closure, and suturing require concentration and practice. The development of new thought patterns regarding surgical esthetics is necessary, and attention must be paid to microanatomy, tissue manipulation, and surgical craftsmanship. [10]

Hand Control

Physiologic tremor

For a basic understanding of the fine finger movements necessary with the use of microscopic magnification, some important aspects of hand function must be reviewed. Finger movements controlled by the long flexor and extensor muscles that move our fingers are relatively crude. Thus, active finger extensions, or flexions, are likely to be relatively crude. However, when the wrist is stabilized by resting on a flat surface, angled in a dorsiflection position at approximately 20 degrees, more accurate, finely controlled finger movement can be accomplished because of the reduction in muscle tremor provided by this "platform." [11],[12]

In microsurgery, the hand should either directly or indirectly rest on an immovable surface or unwanted movements will occur. Only the fingertips move. All movements should be efficient and economical and should be made with a unity of effort toward purposeful, deliberate motions. There are several factors that can influence a surgeon's physiologic tremor, including anxiety, recent exercise, alcohol, smoking, caffeine, heavy meals, hypoglycemia, and medication usage. [11],[12]

Hand grips

Basic hand skills in the United States have been associated with and thought of as an extension of penmanship. With the increased use of keyboards for computers and text messaging on mobile devices, educational curricula no longer stress penmanship. This may play a role in the lack of basic hand skills in the "writing" or penmanship position. The acquisition of poor ergonomic habits prior to and during dental education may increase the time it takes for postgraduate residents to become proficient in microsurgery. The most commonly used precision grip in microsurgery is the pen grip or internal precision grip, which gives greater stability than any other hand grip. [13]

Microsurgical instruments

Microsurgical knives

These knives have their characteristic ability to create clean incisions to prepare the sharp flap margins for healing by primary intention. Using Castroviejo microsurgical scalpel, incisions are made at 90 degrees angles to the surface. Magnification permits easy identification of ragged wound edges for trimming and freshening. Various types of knives such as crescent, lamellar, blade breaker, sclera, and spoon knife can be used. They offer the dual advantage of extreme sharpness and minimal size.

They are designed to hold the fine needles. They differ in the way they grasp the needle e.g. a grasp with flat surface if a flat needle is used.

Microsurgical needles

Periodontists frequently use a reverse cutting needle of a significant size (16 to 19 mm). Microsurgical needles are made of stainless steel directly swaged onto the suture ends. The needle tip may be taper point, conventional cutting, reverse cutting, and spatula or side cutting. The techniques of microsurgery include accurate needle placement, optimal tissue union, and tying of square and slip knots.

Microsurgical sutures

Periodontal microsurgery facilitates the use of 6-0 to 9-0 sutures. Microsurgical wound apposition minimizes gaps or voids at the wound edges, which encourages rapid healing with less post-operative inflammation and pain. When knots are tied under magnification, they are more secure and resist loosening even under functional loads.

Applications of microsurgery in perio-aesthetics

The continuous search for improved surgical procedures to address gingival deformities is a consequence of an increasing demand for aesthetics in the periodontal clinical practice. Innovative techniques have helped clinicians achieve predictability in root coverage. Periodontal plastic surgery is "technique-sensitive" and generally thought to be more demanding than other periodontal procedures. Hence, surgical microscope appears to be a natural evolution in this area of periodontics. Microsurgery has wide implications including the rotational, free gingival, double papilla, and the sub-epithelial connective tissue grafts for the coverage since it causes minimal trauma and enhances the wound healing process. The combination of small microsurgical instruments and delicate surgical techniques allow for extremely fine, crisp and accurate incisions, gentle tissue handling, and precise repositioning of the wound margins with smaller needles and sutures. Along with rapid wound healing, low morbidity and less discomfort, narrow incision lines, and small surgical wounds can add to better esthetic results. Mucogingival surgical procedures designed for the coverage of exposed root surfaces, performed using microsurgical approach, have improved the treatment outcomes substantially and to a clinical relevant level compared with clinical performance under routine macroscopic conditions. [10],[11] The high survival rate of the vascularized graft is due to the retained blood supply from the base of the pedicle, which can be enhanced through microsurgery.

Applications in periodontal flap surgery

Flap reflection in periodontics is to gain exposure of the underlying tissues i.e. bone and the root surface. By using microsurgical techniques, periodontal flap margins can be elevated with uniform thickness that has a scalloped butt-joint. This facilitates precise adaptation of the tissue to the teeth or the opposing flap in an edentulous area, thus eliminating the gaps and dead spaces circumventing the need for new tissue formation and enhancing periodontal regeneration. The use of surgical microscope increases surgical effectiveness and thus has become the indispensable part of periodontal surgical practice. Studies have shown improved initial healing in the sites with microsurgical approach due to more accurate and atraumatic handling of the soft tissues. Further, the coronal displacement of the flaps over the defects was found to be easier and had less tension with the microsurgical technique, which facilitates healing and return of the mucogingival line to its original position. [1],[6] Studies with enamel matrix proteins have shown that enamel matrix derivative could exert better biologic activity in microsurgically treated sites because of reduced tissue trauma and vessel injury to improve vascularization and achieve primary wound closure, which allows optimal retention of enamel matrix derivatives. [12]

Applications in root visualization and preparation

Success of periodontal therapy depends on visual access to the root surface for removing the residual calculus, treating the pathologically altered root surface, and achieving a clean and smooth root surface. Clinical and research studies with stereomicroscopy have demonstrated that the root planing is more effective when done under greater magnification and enhances periodontal regeneration. [13]

Interdental papilla reconstruction

Microsurgical techniques have been developed to replace the lost interdental papilla, which can create phonetic problems, saliva bubbles, and cosmetic deficiencies. A papillary deficiency can be created through iatrogenic surgical removal, as part of tissue collapse following extraction, with periodontal pocket elimination surgery, with periodontal bone loss and with orthodontic separation of overlapped teeth. Success in the treatment of black triangle with periodontal microsurgery is a significant leap in the field of perio-aesthetics, making it a realistic possibility.

Application in gingival recession coverage

Mucogingival surgeries in today's practice are not only concerned with the treatment but also meet the aesthetic demands of the patients. In mucogingival surgeries, the damage to the tissues during surgery can be greatly reduced by atraumatic surgical approach and excellent visualization of the operative field. Therefore, this field of microsurgery enhances the normal vision by magnification and providing with sufficient lighting, leading to improvement in predictability, cosmetic result, and patient comfort levels over conventional periodontal surgical procedures. [14] There was a study conducted in which the comparison between the macro and microsurgical techniques was done for the root coverage using the coronally repositioned flap associated with enamel matrix derivative. It was found that there was a significant reduction in the gingival recession height in both the surgical techniques, which were performed. However, the use of microsurgical technique depicted a greater increase in width of keratinized tissue and thickness of keratinized tissue as compared to the macro- surgical techniques performed. [15],[16],[17],[18],[19]

If attention is paid to details of maintaining the interdental papillae, gingival architecture, and alveolar bone, implant reconstruction can proceed without loss of the pre-existing dental anatomy. The execution of microsurgical technique limits collateral damage. When microsurgical principles are combined with an understanding of microanatomy, the surgeon becomes an architect of unique surgical method.

Three dimensional on-screen microsurgery system

Current advances in video technology permit visualization of the (micro) surgical field on a video monitor three dimensionally without necessitating physical viewing through the microscope. The assembly of the three dimensional on-screen microsurgery system comprises of two single chip video cameras mounted on custom-fit eyepiece adapters, a dual camera-controller, a view/record image processor, a VCR for optional recording, digital monitor to enable viewing, synchronizing signal emitter, and 120 MHz shutter glasses (stereo eyewear). The development of this stereoscopic three-dimensional display technology proficient of providing a clear and accurate sense of depth perception was a boon for the rapidly evolving field of minimally invasive surgery. [20]

Micro-surgical training for periodontists

This part of training of microsurgery has been incorporated in the curriculum of most medical surgical residencies. It even occupies a place in the pre-doctoral medical curriculum, especially emergency medicine. Its use has been seen in other medical specialties such as neurosurgery.

Microsurgical training should be included in the curriculum. The primary teaching focus should be on developing the clinical skills that comprise good microsurgical principles and techniques. Curriculum requires intensive training with direct one-to-one instruction to guide periodontist's skills from introductory to advanced levels. Surgeons learn best with a scalpel or suture in hand. Education through movement concentrates the mind and raises the neurobiology of learning new levels of performance and new possibilities for achievement.

Drawbacks of microsurgery

As we upgrade our surgical maneuvers with the aid of microsurgical concepts, there are a few shortcomings of this modus operandi, which need to be considered prior to its application. It is much more demanding and technique-sensitive; the cost incurred to establish a microsurgical set up is also high. Magnification systems used also pose some difficulties including restricted area of vision, loss of depth of field as magnification increases, and loss of visual reference points. An experienced team approach mandates microsurgery and is time-consuming to develop. Physiologic tremor control for finer movements intra-operatively and a steep learning curve are required for clinical proficiency.

Conclusion

Aesthetic preservation and improvement have become an integral part of today's periodontal treatment. Evaluation of periodontal aesthetic procedures has driven largely by the patient's increased awareness of and desire for aesthetically pleasing smiles. Patients are demanding a youthful attractive smile that includes healthy gingiva with ideal contours and texture. Periodontal microsurgery is definitely a must for perio-aesthetics. The improved visual acuity provided by magnification opens a whole new world for those who make effort and take time to become proficient in microsurgical principles and procedures. The promising periodontal microsurgery will provide new possibilities to improve the therapeutic results for variety of periodontal surgeries.